i

Quality Monitoring Program

Improving Dementia Care

Strategies for Pharmacists in Long-Term Care Facilities

Reducing Reliance on Pharmacological Approaches to Dementia Care

ii

The Quality Monitoring Program (QMP)Quality monitors help detect conditions in Texas nursing homes that could be detrimental to the health, safety and welfare of residents. Quality monitors do not cite deficient practices and are not part of Texas Health and Human Services Long-Term Care Regulatory Services.

During visits, a pharmacist quality monitor might:

• Recommend changes to policies or procedures.

• Conduct staff in-service training.

• Offer technical assistance.

• Educate staff about evidence-based best practices.

QMP resources for long-term care facility staff include handouts, guidance documents, videos, links, archived webinars and trainings.

Good dementia care is everyone’s business. The time is now!

1

Use of Antipsychotic MedicationsAntipsychotic medications are frequently used in nursing homes. There are only a few instances when the use of these medications is suitable for older adults with dementia. Off-label use of antipsychotics to manage dementia-related behaviors shows mixed results and might increase morbidity and mortality. Because of this, the National Partnership to Improve Dementia Care in Nursing Homes has established a nationwide goal of reducing the use of antipsychotic medications in nursing home residents. The partnership includes the Centers for Medicare & Medicaid Services, consumers, advocacy organizations, providers and professional associations.

Texas Health and Human Services and the National Partnership are committed to enhancing the quality of life for people with dementia, ensuring excellent care and promoting goal-directed, person-centered care for every nursing home resident.

Diagnosing SchizophreniaPeople with schizophrenia, schizoaffective disorder and bipolar disorder show symptoms early in life. The highest occurrence of newly diagnosed patients typically falls within ages 20–40. These diagnoses rarely have an onset late in life without prior early-life symptoms. The data suggest that in some Texas facilities, prescribers add new diagnoses, such as schizophrenia, to residents’ clinical records to justify antipsychotic use — even in residents without a history of mental illness. This means many residents with dementia might be subjected to unnecessary mental illness assessments and medications because of inaccurate diagnoses. Making a diagnosis “fit” the medication causes ethical and clinical practice issues. Physicians and other prescribers must be mindful and avoid labeling residents with a diagnosis of schizophrenia or other diagnoses to justify the use of antipsychotic medications.

A number of professional organizations released a joint summary statement related to diagnosing schizophrenia in the long-term care setting. The statement is available at: paltc.org/newsroom/joint-summary-statement-diagnosing-schizophrenia-skilled-nursing-centers.

2

The Role of the PharmacistIn long-term care facilities, pharmacists should:

• Help identify potentially inaccurate mental illness diagnoses.

• Determine the suitability of every dose of antipsychotic medication.

• Assist facility staff in detecting unsuitable antipsychotic use.

• Advocate for improving residents’ quality of care.

Pharmacists are a valuable resource for physicians. By adhering to long-term care facility regulations, pharmacists can help nursing facility staff evaluate the use of antipsychotics and detect unnecessary use. In addition, by emphasizing the treatment of dementia with non-pharmacological approaches, they can reduce the use of potentially harmful medications in nursing homes and other care settings.

Pharmacists evaluate and coordinate all aspects of pharmaceutical services provided to residents by all providers (e.g., pharmacy, prescription drug plan and prescribers). In this role, pharmacists also promote safe, effective medication use by alerting facility staff to excessive or prolonged dosages, inadequate monitoring or indications, and adverse conditions or consequences signifying that dosages need to be reduced or discontinued.

How Pharmacists Can Improve Dementia Care • Partner with medical directors and prescribers to continually

evaluate the outcomes of drug therapy.

• Evaluate every dose to promote gradual dosage reduction when appropriate.

• Encourage documentation of the specific condition and the targeted behavior for the antipsychotic.

• Encourage and review behavioral and side-effect psychotropic monitoring.

• Verify that the nursing staff has assessed for pain or medication side effects as a behavioral cause.

3

• Suggest individualized non-drug interventions and approaches as additions to the plan of care.

• Challenge the facility to increase implementation of non-drug therapy. If there is no evidence of interventions or approaches, speak up!

Non-Drug Therapy WorksNursing home staff can select non-pharmacological approaches to optimize care for people with dementia living in nursing homes instead of using potentially harmful psychotropic medications. Texas Health and Human Services initiatives such as Music & Memory and Reminiscence Activity have already improved the quality of life for many residents. By providing non-drug therapies and focusing on person-centered care, nursing home staff can gradually reduce the use of antipsychotics.

Visit the QMP website at hhs.texas.gov/qmp to learn more about the use of antipsychotic medications, including information related to available non-pharmacological interventions.

HHS Initiatives:• Music & Memory

• One a Month campaign for reducing antipsychotic use

• Reminiscence Activity

• Virtual Dementia Tour

• Alzheimer’s Disease and Dementia Care Seminar

• Texas OASIS: Dementia Care Training

• Person-Centered Thinking Training

• Meaningful Engagement to Enhance Quality of Life Training Academy

• CNA Advanced Training Academy

4

Know the Nursing Facility Regulations*

F757 Unnecessary Drugs: Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); for excessive duration; or without adequate monitoring; without adequate indications for its use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons stated.

F758 Psychotropic Drugs: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic.

Psychotropic Drugs: Based on a comprehensive assessment of a resident, the facility must ensure that:

¡ Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

¡ Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

¡ Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

¡ PRN orders for psychotropic drugs are limited to 14 days. Except if:

¡ the prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident’s medical record and indicate the duration for the PRN order.

5

¡ PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

F755 Pharmacy Services: The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them from an outside resource. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

Procedures: A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

Service Consultation: The facility must employ or obtain the services of a licensed pharmacist who:

¡ Provides consultation on all aspects of the provision of pharmacy services in the facility.

¡ Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

¡ Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

F756 Drug Regimen Review: The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. This review must include a review of the resident’s medical chart. The pharmacist must report any irregularities to the attending physician and the facility’s medical director and director of nursing, and these reports must be acted upon.

¡ Irregularities include, but are not limited to, any drug that meets the criteria for an unnecessary drug.

6

Know the Nursing Facility Regulations*

F756 Drug Regimen Review continued:

¡ Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility’s medical director and director of nursing and lists, at a minimum, the resident’s name, the relevant drug, and the irregularity the pharmacist identified.

¡ The attending physician must document in the resident’s medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident’s medical record.

The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

F760 Significant Medication Errors: The facility must ensure that its residents are free of any significant medication errors.

F761 Labeling of Drugs and Biologicals:Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.Storage of Drugs and Biologicals: In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and

7

Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

F655 Comprehensive Person-Centered Care Planning

Baseline Care Plans: The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must:

¡ Be developed within 48 hours of a resident’s admission.

¡ Include the minimum healthcare information necessary to properly care for a resident including, but not limited to —

¡ Initial goals based on admission orders.

¡ Physician orders.

¡ Dietary orders.

¡ Therapy services.

¡ Social services.

¡ Pre-Admission Screening and Resident Review (PASRR) recommendation, if applicable.

Replacement Baseline Care Plan: The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan:

¡ Is developed within 48 hours of the resident’s admission.

¡ Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

Baseline Care Plan Summary: The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:

¡ The initial goals of the resident.

¡ A summary of the resident’s medications and dietary instructions.

8

Baseline Care Plan Summary continued: ¡ Any services and treatments to be administered by

the facility and personnel acting on behalf of the facility.

¡ Any updated information based on the details of the comprehensive care plan, as necessary.

F656 Comprehensive Care Plans:The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Comprehensive Care Plan contents: The comprehensive care plan must describe the following:

¡ The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and

¡ Any services that would otherwise be required but are not provided due to the resident's exercise of rights, including the right to refuse treatment.

¡ Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASRR recommendations. If a facility disagrees with the findings of the PASRR, it must indicate its rationale in the resident’s medical record.

¡ In consultation with the resident and the resident’s representative(s):

¡ The resident’s goals for admission and desired outcomes.

¡ The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.

¡ Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements.

Know the Nursing Facility Regulations*

Learn more at CMS.gov, including clarification on federal regulations for the care of residents with dementia, materials related to the National Partnership to Improve Dementia Care in Nursing Homes and access to the State Operations Manual/Appendix PP, which is available at cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

Texas Health and Human ServicesQuality Monitoring ProgramMail Code W-510 P.O. Box 149030 Austin, TX 78714-9030

Email: QMP@hhsc.state.tx.us

Fax: 512-438-5768 (Faxes should be sent to the attention of the Quality Monitoring Program)

hhs.texas.gov/qmp

Be sure to follow the Texas Nursing Facility Quality Improvement Coalition on Facebook.

10

HHS COMM 18D0736 • July 2018